comorbidities in cerebr

8/22/2019 Comorbidities in Cerebr

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Comorbidities in cerebral palsy and theirrelationship to neurologic subtype andGMFCS level

Michael I. Shevell, MD,

CM, FRCPC

Lynn Dagenais, BSc

Nicholas Hall, BSc

On behalf of the

REPACQConsortium*

ABSTRACT

Objective: Utilizing a population-based registry, the burden of comorbidity was ascertained in a

sample of children with cerebral palsy and stratified according to both neurologic subtype and

functional capability with respect to gross motor skills.

Methods: The Quebec Cerebral Palsy Registry was utilized to identify children over a 4-year birth

interval (1999–2002 inclusive) with cerebral palsy. Information on neurologic subtype classified

according to the qualitative nature and topographic distribution of the motor impairment on neu-

rologic examination, Gross Motor Function Classification System (GMFCS) categorization of mo-

tor skills, and the presence of certain comorbidities (cortical blindness, auditory limitations,

nonverbal communication skills, gavage feeding status, and coexisting afebrile seizures in the

prior 12 months) was obtained.

Results: The frequency of individual comorbidities, their proportional distribution, and mean num-

ber of occurrences basically falls into a significant dichotomous distribution. Across the spectrum

of comorbidities considered, these comorbidities are relatively infrequently encountered in those

with spastic hemiplegic or spastic diplegic variants or ambulatory GMFCS status (levels I–III),

while these entities occur at a frequent level for those with spastic quadriplegic, dyskinetic, or

ataxic-hypotonic variants or nonambulatory GMFCS status (levels IV and V).

Conclusion: The enhanced burdens of comorbidity are unevenly distributed in children with cere-

bral palsy in a manner that can be associated with either a specific neurologic subtype (spastic

quadriplegic, dyskinetic, ataxic-hypotonic) or nonambulatory motor status (Gross Motor Function

Classification System levels IV and V). This provides enhanced value to the utilization of these

classification approaches. Neurology ® 2009;72:2090–2096

GLOSSARY

GMFCSϭGross Motor Function Classification System; REPACQϭQuebec Cerebral Palsy Registry.

The sine qua non of cerebral palsy is early onset objective signs of motor impairment that isboth cerebral in origin and the product of a nonprogressive lesion to the developing CNS. 1 It

has been well recognized that this can occur in conjunction with a variety of comorbid condi-tions.2 The co-occurrence of these conditions are explicitly recognized in the most recentconsensus definition for cerebral palsy.3 Several complementary classification schemes for cate-

gorizing cerebral palsy have emerged over time. The most common in clinical use are a classifi-cation scheme based on neurologic subtype and another based on functional skills in the gross

motor domain.4-8

For many children with cerebral palsy, it is these co-occurring conditionsthat may often have the greatest impact on the child and family from varying perspectives. 1

Ideally, systematic programmatic follow-up of children with cerebral palsy will permit therecognition of these coexisting entities.9-12

Address correspondence and

reprint requests to Dr. Michael

Shevell, Room A-514, Montreal

Children’s Hospital, 2300

Tupper, Montreal, Quebec,

Canada, H3H [email protected]

*Members of the REPACQ Consortium are listed in the appendix.

From the Departments of Neurology/Neurosurgery and Pediatrics (M.I.S., N.H.), McGill University; Division of Pediatric Neurology (M.I.S.,

N.H.), Centre de Readaptation Marie-Enfant du CHU Ste Justine (L.D.); and Montreal Children’s Hospital–McGill University Health Center

(M.I.S., N.H.), Montreal, Quebec, Canada.

Disclosure: The MCH Foundation provided salary support for Dr. Shevell and the RSDBE of the FRSQ and the CP Research Chair of Laval

University provided operational funding of REPACQ.

2090 Copyright © 2009 by AAN Enterprises, Inc.



Population-based cerebral palsy registries

provide an opportunity to capture the entire

spectrum of cerebral palsy in a community in

a relatively unbiased way.13 Identification of

readily available predictor variables will assist

us in such domains as counseling, prognosti-

cation, and selective program emphasis on

particular subgroups.

The objective of this study was to utilize a population-based registry to classify cerebral

palsy by both subtype and functional level

and identify the burden of certain comorbidi-

ties across the stratifications of each of these

classification schemes. As a corollary, associa-

tions between particular cerebral palsy sub-

types, either neurologic or functional, and

individual comorbidities were sought.

METHODS Subjects were recruited through the Quebec Ce-

rebral Palsy Registry (REPACQ). This Registry was established

in 1998 by a multidisciplinary consortium of clinicians and re-

searchers with an interest in cerebral palsy. After an initial effort

over 4 years in conjunction with international experts and then

existing cerebral palsy registries (i.e., Western Australia,14

SPCE15) to reach a consensus on the definition and diagnosis of

cerebral palsy, mechanisms of case ascertainment, data variables

to be collected, and mechanisms of data collection, the Registry

became operational in 2004 in 6 of 17 geographically defined

administrative health and social service regions of the province of

Quebec, representing roughly half of the province’s population

and annual births. Cases were ascertained through systematic

surveys of regionalized pediatric rehabilitation and medical ser-

vice providers. Quebec has a universal third party (i.e., govern-ment funded) program of medical and rehabilitation service

provision available to all provincial residents. Regionalization re-

quires that those children requiring rehabilitation service provi-

sion for their needs are serviced through local specialized centers

responsible for a specific defined geographic region. Once cases

were identified, parents (or guardians where necessary) were ap-

proached for consent to participate in the Registry. Once con-

sent was obtained, over 120 variables pertaining to each case

were sought through a combination of direct review of maternal

and child medical and rehabilitation records and parental (pref-

erably maternal) interview.

Cases were ascertained only once a child was beyond the age

of 2 years and where possible confirmed at 5 years of age. Cere-

bral palsy was defined as per recent consensus statements as a

nonprogressive motor impairment of early onset, that is presum-

ably cerebral in origin, which may or may not be associated with

developmental delays, cognitive disability, language impairment,

epilepsy, sensory (auditory or visual) loss, orthopedic abnormali-

ties, or behavioral difficulties.3,16,17 A recognized motor impair-

ment required objective changes in tone, muscle strength,

posture, reflexes, and motor skills on examination for diagnosis.

Nonprogressive referred to the underlying pathologic process

and not apparent clinical manifestations. Genetic and metabolic

disorders considered as per Badawi et al.18 were excluded from

consideration. Early onset meant signs and symptoms were evi-

dent prior to 1 year of age. By definition, neuromuscular disor-

ders and myelodysplasias were excluded from diagnosis. Data

were obtained in a systematic fashion by duly trained research

assistants according to established written procedures and train-

ing protocols and a subset was checked for accuracy prior to

registry inscription. Data were obtained on demographic fea-

tures, maternal medical and obstetric history, labor and delivery

of the affected child, neonatal course, age at onset, diagnostic

investigations and their results, type of cerebral palsy, gross mo-

tor functional status, various coexisting medical and comorbid

conditions, and medical and rehabilitation service provision

(both previously and at the time of inscription). Data extraction was conducted by trained local research assistants according to

standardized policies and procedures supervised consistently by a

single individual. A subset was randomly selected for indepen-

dent validation of accuracy. Ethical permission was obtained at

the local host institution (McGill University Health Center) and

each participating pediatric rehabilitation center.

For this study, subjects were children born in 1999–2002 (a

4-year inclusive birth cohort). When both were recorded the sub-

type of cerebral palsy and gross motor functional status was ex-

tracted. The subtype of cerebral palsy was classified according to the

quality and topographic pattern of motor impairment last docu-

mented by an objective assessment employing the following well-

utilized clinical scheme: 1) spastic-quadriplegic (spasticity

[symmetric or asymmetric] in all four limbs with equivalent or

greater spasticity in the upper extremities), spastic-hemiplegic (spas-

ticityrestricted to oneside of the body with relative variable involve-

ment of the upper and lower extremity), spastic-diplegic (spasticity

in the lower extremities far in excess of any discernable in the upper

extremities which or may not be relatively asymmetric), or spastic-

other (spasticityin onelimb or in alllimbsexceptone); 2) dyskinetic

(i.e., athetosis, chorea, or dystonia in the absence of objective weak-

ness or tone changes); 3) ataxic-hypotonic. Those with a mixed pro-

file of dyskinetic and spastic features were counted as dyskinetic.

Similarly, the last objective assessment was utilized to assign func-

tional mobility according to the Gross Motor Function Classifica-

tion System (GMFCS).19 This relativelyrecently developed measure

provides an assessment of a child’s gross motor function andabilitiesin early life emphasizing the stratification of function into categories

that capture meaningful differences for child and family from most

able (level I) to most limited (level V).8 Content validity, reliability,

consistency, and predictive validity have been established for this

now widely employed measure.20-22 Independent ambulation, with-

out(level I andlevel II) andwith assistance (level III),can be reliably

distinguished and inferred in this approach from nonambulation

(level IV and level V).

Several different comorbidities are the focus of this article;

cortical blindness, substantial auditory impairment, nonverbal

communication skills, gavage feeding status, and coexisting sei-

zures. The age of the children (between 2 and 5 years) precluded

reliable assessment of possible cognitive disability. Lack of accessto psychiatric information precluded data collection regarding

behavioral disorders. Information pertaining to these comorbidi-

ties was specifically sought for in the medical records reviewed

and in the parental interview conducted at the time of obtaining

data for Registry inscription. Cortical blindness required diagno-

sis by an ophthalmologist. Substantial auditory impairment was

defined as a 70 dB or greater hearing loss (bilateral) on audio-

metric testing. Nonverbal referred to the absence of specific

words or recognizable vocabulary in the child’s maternal lan-

guage irregardless of possible etiology (i.e., motor or cognitive

limitations). Gavage feeding referred to the use of a temporary or

permanent artificial tube to administer the bulk of a child’s nu-

trition internally. Coexisting seizures was defined as the occur-

Neurology 72 June 16, 2009 2091



rence of afebrile seizures in the 12 months preceding Registry

inscription.

Individual comorbidities noted were tabulated across cere-

bral palsy subtype and GMFCS level. The proportions of chil-

dren with each comorbidity were compared dichotomously

between spastic quadriplegia or dyskinetic subtypes (grouped to-

gether) and all other subtypes by Pearson 2analysis. Similarly,

the proportion of children with each comorbidity was comparedbetween GMFCS levels grouped dichotomously into ambula-

tory (levels I–III) and nonambulatory (levels IV and V) subsets.

Similarly, the mean number of comorbidities was tabulated

across cerebral palsy subtypes and GMFCS levels separately with

Student t test of means used to compare the means obtained for

the dichotomous groupings of neurologic subtype and GMFCS

levels outlined previously. A p value of 0.05 or less was chosen a

priori to denote significance.

RESULTS In all, 301 children were identified in the

six administrative regions comprising REPACQ over

the 4-year inclusive birth interval (1999–2002).

Given roughly 144,000 live births in these same re-gions over this interval, this yields a crude prevalence

of 2.09 per 1,000 live births, in the middle of the

1.5–2.5/1,000 live births range quoted in the litera-

ture for developed regions analogous to Quebec.23

Concurrent information on cerebral palsy subtype

and GMFCS level was available on 243 of these chil-

dren and it is this group which comprises the study

cohort. The children were a mean age of 44 months

(SD 14 months, range 24–79 months) at the time of

registry inscription. The individual comorbidity fre-

quency distribution by neurologic subtype and

GMFCS level are reported in tables 1 and 2. The

mean number of comorbidities experienced by a sin-

gle child is reported by stratification by neurologic

subtype and GMFCS level in table 3. The results of

Pearson 2

analysis for the proportional distributionof individual comorbidity dichotomously grouped

into either spastic quadriplegic/dyskinetic or other

cerebral palsy subtypes and ambulatory (levels I–III)

or nonambulatory (levels IV and V) GMFCS status

are reported in table 4. The results of Student t tests

of the means of the total number of comorbidities

experienced for each child for these same dichoto-

mous groupings are reported in table 5.

For all comorbidities considered, the difference in

proportional distribution between the spastic quadri-

plegic/dyskinetic and all other cerebral palsy subtypes

was significant. Similarly, the difference in propor-

tional distribution of all individual comorbidities was

significant between the ambulatory (levels I–III) and

nonambulatory (levels IV and V) GMFCS group-

Table 2 Frequency of comorbidities distributed by GMFCS level

GMFCSlevel

Severe visualimpairment(n 23)

Severeauditoryimpairment(n 28)

Nonverbal(n 54)

Gavagefeeding(n 19)

Seizureslast 12mo(n 41)

I ( n 108) 4 (4) 6 (6) 1 (1) 4 (4) 7 (6)

I I (n 23) Ϫ (Ϫ) 3 (13) Ϫ (Ϫ) Ϫ (Ϫ) 3 (13)

I II (n 30) 1 (3) 4 (13) 6 (20) Ϫ (Ϫ) 5 (17)

I V (n 43) 5 (12) 7 (16) 15 (35) 3 (7) 9 (21)

V ( n 39) 13 (33) 8 (21) 32 (82) 12 (31) 17 (44)

Valuesare n (%).

GMFCSϭGross Motor Function Classification System.

Table 1 Frequency of comorbidities distributed by neurologic subtype

Neurologic subtype

Corticalblindness(n 23)

Severeauditoryimpairment(n 28)

Nonverbal*(n 54)

Gavagefeeding(n 19)

Seizureslast 12mo*(n 41)

Spastic quadriplegia(n 85) 18 (21) 12 (14) 38 (45) 14 (17) 26 (31)

Spastic hemiplegia (n 77) 2 (3) 4 (5) 2 (3) 1 (1) 6 (8)

Spastic diplegia (n 52) 1 (4) 3 (6) 1 (4) 2 (4) 3 (6)

Dyskinetic (n 16) 1 (7) 6 (38) 8 (50) 2 (13) 1 (7)

Ataxic-hypotonic (n 9) 1 (11) 3 (33) 4 (44) Ϫ (Ϫ) 4 (44)

Values are n (%).

*Four children with spastic triplegia or monoplegia were excluded from analysis. One child with spastic triplegia was non-

verbaland another had seizures in the prior 12 months.

Table 3 Mean ( SD)number of comorbidities

(range 0 –5) stratifiedby neurologic

subtype andGMFCS level

Neurologic subtype Mean SD

Spastic hemiplegia 0.19 Ϯ 0.91

Spastic diplegia 0.19 Ϯ 0.89

Dyskinetic 1.13 Ϯ 0.77

Spastic quadriplegia 1.27 Ϯ 1.10

Ataxic-hypotonic 1.33 Ϯ 1.00

GMFCS level

I 0.20 Ϯ 0.92

II 0.26 Ϯ 0.97

III 0.53 Ϯ 0.95

IV 0.91 Ϯ 1.03

V 2.10 Ϯ 0.97

GMFCSϭGross Motor Function Classification System.

2092 Neurology 72 June 16, 2009



ings. The mean number of comorbidities experi-

enced between those in the spastic quadriplegic/

dyskinetic and the other subtypes and the ambulatory

(levels I–III) and nonambulatory (levels IV and V)

groupings were also different at a significant level.

For each individual comorbidity and for the bur-den of comorbidity taken collectively, a higher

proportion and a higher mean number were evi-

dent in either the spastic quadriplegic/dyskinetic

or nonambulatory (levels IV and V) subgroups

compared to the other dichotomous group within

each respective classification scheme.

DISCUSSION The results from our population-

based registry indicate that each of the comorbidities

evaluated occurred in less than a quarter of the group

of children with cerebral palsy as a whole with the

following decreasing frequency distribution docu-

mented: nonverbal 22.2% (54/243), active afebrile

seizure disorder 16.9% (41/243), severe auditory im-

pairment 11.5% (28/243), cortical blindness 9.5%

(23/243), and gavage feeding requirement 7.8% (19/

243). Clustering of comorbidities, both individually

and collectively, was readily apparent when consider-

ing the classification of cerebral palsy from either a

neurologic or functional perspective. Children with

ataxic-hypotonic (1.33 Ϯ 1.00), spastic quadriplegic

(1.27Ϯ 1.10), and dyskinetic (1.13Ϯ 0.77) cerebral

palsy variants experienced at a mean level roughly

five times the numerical burden (i.e., frequency) of comorbidities compared to children with the spastic

diplegic (0.19 Ϯ 0.89) or hemiplegic (0.19 Ϯ 0.91)

variants. Similarly, there was a marked elevation in

comorbidity burden with each increment above a

GMFCS level II, with a 10-fold difference noted be-

tween those at level I (0.20Ϯ 0.92) and level V (2.10Ϯ

0.97). Furthermore, of 165 separate comorbidities

documented among the 243 subjects, 138 (84%) oc-

curred among children with the spastic quadriplegic,

dyskinetic, and ataxic-hypotonic variants and 121

(73%) occurred among nonambulatory (GMFCS

Table 4 Pearson 2 analysis of proportional distribution of comorbidity: Spastic quadriplegic/dyskinetic

subtypes vs other cerebral palsy subtypes;GMFCS levelsI–III (ambulatory)vs GMFCS levelsIV

and V (nonambulatory)

Spasticquad/dyskinetic(n 101 )

Othercerebralpalsysubtype(n 142 )

2 p Value

GMFCSlevelsI–III(n 161)

GMFCSlevelsIVand V(n 82)

2 p Value

Severe visual

Yes 19 4 17.62 Ͻ0.001 5 18 22.52 Ͻ0.001

No 82 138 156 64

Severe auditoryimpairment

Yes 18 10 9.56 0.003 13 15 8.27 0.007

No 83 132 148 67

Nonverbal

Yes 46 8 31.28 Ͻ0.001 7 47 55.04 Ͻ0.001

No 55 134 154 35

Gavage feeding

Yes 16 3 15.02 Ͻ0.001 4 15 18.4 Ͻ0.001

No 85 139 157 67

Seizureslast12 mo

Yes 27 14 11.46 0.001 15 26 18.81 Ͻ0.001

No 74 128 146 56

GMFCSϭGross Motor FunctionClassification System.

Table 5 Student t tests of mean numberof

comorbidities:Spastic quadriplegic/

dyskinetic subtypesvs othercerebral

palsysubtypes and GMFCSlevelsI–III(ambulatory)vs GMFCSlevels IV

and V (nonambulatory)

Mea n SDStudentt test

Spastic quadriplegic/dyskinetic

1.25Ϯ 1.05 pϽ 0.001

Other cerebral palsysubtype

0.27Ϯ 0.97

Levels I–III 0.27Ϯ 0.97 pϽ 0.001

LevelsIV andV 1.48Ϯ 1.05

GMFCSϭGross Motor FunctionClassification System.




levels IV and V) children, though these groupings

represented respectively 45% and 34% of the sample

population as a whole.

Within some subgroupings, a particular comor-

bidity was a common (greater than 25% frequency)

occurrence. For children with spastic quadriplegia,

this was represented by nonverbal status (38/85,

45%) and coexisting seizures (26/85, 31%). For dys-

kinetic children, nonverbal skills (8/16, 50%) and

auditory impairment (6/16, 38%) occurred espe-

cially frequently. For level IV GMFCS stratified chil-

dren, being nonverbal was especially evident (15/43,

35%). All comorbidities, with the relative exception

of severe auditory impairment, occurred particularly

frequently (nonverbal [32/39, 82%], coexisting sei-

zures [17/39, 44%], cortical blindness [13/39, 33%],

and gavage feeding requirement [12/39, 31%])

among level V GMFCS children. Across the spec-

trum of specific comorbidities evaluated, for children

with spastic hemiplegic or spastic diplegic variants,

the comorbidities were infrequent (Ͻ10%) occur-rences and similarly for level I GMFCS children.

2

analysis through contrasting dichotomous groupings

of subtypes (spastic quadriplegic/dyskinetic vs other

cerebral palsy subtypes and levels I–III GMFCS vs

levels IV and V GMFCS) confirmed that these dif-

ferences in the proportional distributions docu-

mented were indeed significant.

Thus from varying approaches, it is readily appar-

ent that the varying comorbidities encountered in ce-

rebral palsy are not equally distributed across the

population of children afflicted with this neurodevel-

opmental disability. Whether utilizing a system

based on neurologic observation and examination4-6

or one employing meaningful functional differences

in gross motor skills,8 particular subtypes are espe-

cially associated with the occurrence of one or more

comorbidities. This suggests a burden beyond that

captured inherently by either classification itself that

will challenge the child, family, and health service

providers.

Though not part of their conceptualization and

formulation,23 both classification schemes go beyond

simply describing in their complementary ways neu-rologic deficits or motor limitations. They also ap-

pear to impart a profile of expectations (i.e., risks)

with respect to the occurrence of various comorbidi-

ties that can inform and guide clinical approach,

counseling and programmatic efforts, and prognosti-

cation. Clearly, identification and intervention ef-

forts targeting these various comorbidities would best

be directed toward children with spastic quadriple-

gic, dyskinetic, and ataxic-hypotonic variants or level

IV and V GMFCS status assignment. Since both of

these classification schemes can be applied at an early

age with measurable (though not complete) stability

and confidence,17-24 this provides for the clinician a

simple mechanism for rendering a child at risk for

sequelae that have the potential to limit participation

and quality of life and are also possibly amenable to

intervention that are best served by early detection.

This unexpected and unintended profiling utility for

these classification schemes is an added value and

benefit that reinforces their known strengths.7,8 It is

not surprising that both of these classification

schemes impart such profiling as they have been

shown to covary.25,26

Under the influence of the International Classifi-

cation of Functioning, Health & Disability model,

our emphasis in the neurodevelopmental disabilities

has shifted to a focus on overall health, and especially

participation, which are predicates for an individual’s

quality of life.27 Comorbidities are likely to be impor-

tant determinants of health, participation, and qual-

ity of life, which are under both intrinsic and

extrinsic influences.28,29

It appears from this study that the actual categorical type of cerebral palsy may

be one of these intrinsic factors. An additional ave-

nue of future study suggested by our results are what

factors, both intrinsic and extrinsic, are the determi-

nants of comorbidity occurrence among each of the

high frequency subtypes identified? At present, what

such factors are remains open to speculation though

a recent study has highlighted clinical (i.e., neonatal

encephalopathy, microcephaly, GMFCS IV or V

level) and radiologic (i.e., periventricular leukomala-

cia) features among children with spastic quadriple-

gic cerebral palsy.9

Our study represents the first report from a North

American population-based cerebral palsy registry re-

garding varying comorbidities in this particular neuro-

developmental disability. It most resembles a recent

study from western Sweden that focused on intellectual

impairment, epilepsy, and severe visual impairment co-

morbidities.30 As in our study, a relationship between

particular CP neurologic subtype, GMFCS level, and

comorbidity occurrence was documented. No informa-

tion was provided on verbal skills, severe auditory im-

pairment, or feeding status. A higher frequency of severevisual impairment was noted in the Swedish study,

likely due to their additional consideration or inclusion

of severe myopia. A recent first report from a Norwe-

gian CP registry reported comorbidity occurrence, but

omitted information pertaining to the child’s functional

motor status in this context.31 With respect to neuro-

logic subtype, this report grouped together classically

distinguished spastic quadriplegic and diplegic variants,

which have vastly different functional motor and co-

morbidity status, into a single bilateral spastic CP

grouping. Another report from southern Sweden on a




smaller cohort of children (n ϭ 167) focused on three

comorbidities (intellectual impairment, epilepsy, severe

visual impairment), but omitted analysis of a relation-

ship to CP subtype or the important discriminator of

ambulant vs nonambulant motor status.32 A final recent

study from the United Kingdom combined data from

five different registries utilizing different methods of

data collection, without the context of either neurologic

subtyping or GMFCS stratification.33

This population-based study has documented the

frequency of selected comorbidities evident before

the age of 5 years in children with cerebral palsy.

Timing of Registry inscription and available data

precluded consistent reliable determination of intel-

lectual and behavioral comorbidity, thus our study

inherently underestimates the overall comorbidity

burden. The burden of comorbidities falls dispropor-

tionately on those children with spastic quadriplegic,

dyskinetic, or ataxic-hypotonic variants and GMFCS

level IV or V functional limitations. This illustrates

an added benefit for utilization of both of these clas-sification approaches and has clear clinical implica-

tions with regards to our programmatic efforts,

counseling, and prognostication in this neurodevel-

opmental disability. The facility of use and the

potential near-universal application of these classifi-

cation schemes provides an opportunity to endeavor

to attain early identification of varying comorbidities

among at-risk subgroups that may ultimately lead to

a more optimal outcome for these children.

ACKNOWLEDGMENT

The authors thank Alba Rinaldi for s ecretarial assistance and Anna Radzi-och for creating the tables.

APPENDIX

REPACQ Consortium (Contributors): Marie-Danielle Boucher, MD

(Quebec City); Claude Desjardins, MD (Hull); Josee Fortier, MD (Trois-

Rivieres); Louise Koclas, MD (Montreal); Celine Lamarre, MD (Mon-

treal); Francine Malouin, PT, PhD (Quebec City); Jean Mathieu, MD,

MSc (Chicoutimi); Diane Munz, MD (Montreal); Nicole Pigeon, MD

(Sherbrooke); Carol L. Richards, PT, PhD (Quebec City).

ReceivedNovember18,2008. Accepted in final formMarch31,2009.

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DOI 10.1212/WNL.0b013e3181aa537b2009;72;2090 Neurology

Michael I. Shevell, Lynn Dagenais and Nicholas HallGMFCS level

Comorbidities in cerebral palsy and their relationship to neurologic subtype and

October 27, 2012This information is current as of

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